Best practice & research. Clinical anaesthesiology
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Opioid-free anesthesia (OFA) is emerging as a new stimulating research perspective. The rationale to propose OFA is based on the aim to avoid the negative impact of intraoperative opioid on a patient's postoperative outcomes and also on the physiology of pathways involved in intraoperative nociception. ⋯ OFA has been shown to be feasible but the literature is still scarce on the clinically meaningful benefits for patients as well as on the side effects and/or complications that might be associated with it. This review focused first on the physiology of nociception, the reasons for using or not using opioids during anesthesia, and then on the literature reporting evidence-based proofs of benefits/risks associated with OFA.
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Best Pract Res Clin Anaesthesiol · Sep 2019
ReviewPostoperative pain management in the era of ERAS: An overview.
Enhanced recovery after surgery (ERAS) programmes are increasingly becoming standard of care for several surgical procedures. However, compliance with ERAS protocols including pain management protocols remains poor. ⋯ This approach should facilitate incorporation of pain management recommendations in an ERAS protocol and improve compliance with the protocols. This article presents an improved approach to developing pain management guidelines as well as a pragmatic approach to procedure-specific perioperative pain management that could be incorporated in an ERAS pathway.
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Best Pract Res Clin Anaesthesiol · Sep 2019
ReviewPostoperative acute pain challenges in patients with cancer.
It is expected that the number of surgical procedures to diagnose, treat, and palliate cancers will increase in the near future. While many of those interventions can be performed with minimally invasive techniques, others require surgical large incisions and in some instances, they involve multiple areas of the body (i.e., tumor resections with flap reconstructions). Pain after major oncological procedures can be severe and many times difficult to treat as patients can present to the operating room with several conditions including preoperative pain (i.e., rapidly growing tumors and painful neuropathies), opioid tolerance, and contraindications to nonopioid analgesics or regional anesthesia. ⋯ Furthermore, it has been theorized that poorly treated pain is associated with cancer recurrence and a reduced survival. Lastly, recent research questions the oncological safety of robotic surgery in gynecological procedures and indicates the need of open surgeries, which will be associated with an increased risk in moderate-to-severe postoperative pain. In conclusion, the management of acute postoperative pain in patients with cancer can be challenging.
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Best Pract Res Clin Anaesthesiol · Sep 2019
ReviewPain measurement and critical review of analgesic trials: pain scores, functional pain measurements, limits and bias of clinical trials.
Randomized clinical trials designed to assess analgesic agents and/or techniques used for postoperative pain control have several limitations, which are addressed in this article. Efficacy of analgesics cannot be limited to the evaluation of pain intensity or the amount of opioid rescue medication, but it also means to evaluate parameters such as the delay and duration of the effect, the number of patients with satisfactory pain control, and side effects. Because combination of analgesics is the standard of care in clinical practice, its value also needs to be documented. Eventually, analgesic treatments have to be considered in the settings of postoperative supportive care and enhanced recovery programmes after surgery.
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Best Pract Res Clin Anaesthesiol · Sep 2019
ReviewPeripheral nerve catheters: A critical review of the efficacy.
Continuous peripheral nerve blocks are commonly used for postoperative analgesia after surgery. However, catheter failure may occur due to either primary (incorrect insertion) or secondary reasons (displacement, obstruction, disconnection). Catheter failure results in unanticipated pain, need for opioid use, and risk of readmission or delay in hospital discharge. ⋯ Thirty-three studies met the selection criteria, comprising 2711 catheters. Literature review suggests that peripheral nerve catheters have clinically significant failure rate when the assessment is performed using an objective (imaging) method. Subjective methods of assessment (without imaging) may underestimate the incidence of catheter failure.